HNY Policy and Pathway Repository - York

The presence of blood in a man’s ejaculate.

• Most cases have no identified cause.
• Common causes include prostate inflammation or infection.
• Rarely, it can be a result of prostate/ bladder or testicular malignancy.

• Frank haematuria
• Testicular mass
• Abnormal Prostate on examination
• Elevated age-specific PSA

Baseline Investigations

• Clinical examination, to include testes and prostate examination
• Urinalysis (to exclude haematuria) +/- urine culture.
• Offer PSA testing (when appropriate- any accompanying LUTS or abnormality on examination).
• Consider FBC, Coag for recurrent haematospermia.

Management

• If the person is under 40 years old, and no underlying cause is identified by initial assessments and investigations, reassure them that a single episode is likely to be benign and self-limiting, advise to return if the problem continues.
• Consider STIs and if appropriate refer to YorSexual Health Clinic (01904 721111)
• If a urinary tract infection is suspected, treat with antibiotics based on the results of culture and sensitivity tests.
• Consider BP check and ensure BP in range if hypertensive.
• If acute prostatitis is suspected
  • Offer a 4 week prescription of either trimethoprim 200mg BD (first line) or ciprofloxacin 500mg BD (second line). Four weeks treatment may prevent chronic prostatitis. Advise patients about the possible adverse effects with fluoroquinolones antibiotics. fluoroquinolones such as ciprofloxacin can very rarely cause long-lasting (up to months or years), disabling, and potentially irreversible adverse effects, sometimes affecting multiple systems, organ classes, and senses. Patients should stop treatment with a fluoroquinolone antibiotic at the first signs of a serious adverse reaction, such as tendonitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and central nervous system effects, and to contact their doctor immediately
  • Provide pain relief with paracetamol and/or ibuprofen. For severe pain, offer codeine with paracetamol – not to be prescribed long term.
  • If defecation is painful, offer a stool softener such as docusate or lactulose.
• If chronic prostatitis is suspected
  • Offer a single course of antibiotics, if symptoms have been present for less than 6 months. Consider prescribing trimethoprim 200 mg BD for 4–6 weeks or azithromycin 500mg once a day, three times a week for 3 weeks.
  • Prescribe paracetamol and/or a NSAID such as ibuprofen for pain relief, do not prescribe opioids in chronic prostatitis.
  • Patients with significant lower urinary tract symptoms (LUTS) should be offered a 4– 6 week trial of an alpha-blocker, this should not be prescribed at the same time as an antibiotic.
  • Prescribe a stool softener such as lactulose or docusate if defecation is painful.
  • Consider referral to a urologist assessment and management, if symptoms persist after initial management.

Refer to Urology:

• Consider 2WW referral
  • for Testicular lesions/ Abnormal Prostate/ ^ PSA/ Haematuria.
     
• Routine Referral
  • for Men > 40 years with no identifiable cause for haematospermia.
  • Men and boys of any age who have experienced more than ten episodes of haematospermia, with no identifiable cause.
  • Refer if investigations have suggested that the underlying cause of haematospermia may be cysts or calculi of the prostate or seminal vesicles.
  • Refractory unexplained cases of haematospermia.

Refer to Haematologist if the person has signs and symptoms suggestive of an acquired bleeding disorder, lymphoma or leukaemia

General Advice

• Reassure the person that most causes of haematospermia have no effect on fertility. The main exception to this is when the underlying cause is certain sexually transmitted infections.
• Reassure men who have had a recent prostate procedure that any associated haematospermia should resolve within three to four weeks.

References

https://cks.nice.org.uk/haematospermia 

https://cks.nice.org.uk/haematospermia#!scenario